Prepared By :- GHADA ALMUKHAINISupervised by :- PROF.DR. ELHAM FAYADH

King Saud UniversityCollege of NursingGraduate program

• State the Goals of the Therapeutic Nursing-patient relationship.

• Discuss the elements affecting the nurse’s ability to be therapeutic.

• Discuss the nurse's tasks and possible problems in the four phases of the relationship.

• Examine the level of communication, two modes of the communication process.

• Discuss the therapeutic communication Technique.

• Analyze how the nurse uses the responsive dimensions in a therapeutic communication.

• Analyze how the nurse uses each of the action dimensions in a therapeutic relationship.

• Evaluate therapeutic Impasses.

• Nurse-patient Relationship:--Definition-Goal of Nurse-patient relationship-Characteristics of the relationship.-phases of the relationship.• Elements of the affecting the nurses abilities to be

therapuetic.• Personal Qualities of the nurse.• Facilitative communication.-verbal communication VS non verbal

communication

• Communication process.• Model of the communication process• Therapeutic communication technique.• Responsive Dimensions • Action Dimensions• Therapeutic Impasses.

• Is a mutual learning experience and a corrective emotional experience for the patient.

• It is based on the underlying humanity of nurse and patient.

• It is a mutual respect and acceptance of sociocultural difference.

• Self-realization , self acceptance , and an increased genuine self-respect.

• A Clear sense of personal identity and an improved level of personal integration.

• Ability to form intimate ,interdependent, interpersonal relationships with a capacity to give and receive love.

• Improve functioning and increased ability to satisfy needs and achieve realistic personal goals.

• It is a Vital characteristics of the nurse-patient is sharing of behavior, thoughts, feelings.

• Social relationship :2 people are part of a natural social network.

• Professional relationship: is based on clear role expectations.

• Apply to all clinical setting

• Preinteraction phase• Introductory phase• Orientation phase• Working phases• Termination phase

• Explore own feeling, fantasies, and fears .commonly for students ( self-exploration).

• Analyze own professional strengths and limitations.

• Gather data about patient when possible.

• Plan for first meeting with patient.

• Nurse-Patient are stranger to each other.

• Determine why patient sought help.

• Formulating a contract: Establish trust, acceptance, open communication.

• It involve a mutual agreement on specific goal.

• Explore feelings: discomfort & nervousness.

• Patient & nurse explore stressors.

• Promote development of insight in the patient.

• These insight should translated into action and a change in behavior.

• Patient often display resistance, it involves the greater part of the problem-solving process.

• Important phase.

• Establish reality of separation.

• Review progress of therapy and attainment of goals.

• Mutuality explores feelings of rejection, loss, sadness, anger.

Elements affecting the nurse’s ability to be Therapeutic

1. Self- awareness

2. Clarification of value.

3. Exploration of feelings

4. Role modeling

5. Altruism

6. Ethics& responsibilities

• Self awareness is the key part of the

psychiatric nursing experience, and the nurse’s

goal is to achieve authentic, open and personal

communication.

• The nurse must be able to examine personal

feelings, actions and reactions.

• Values:- formed as a result of life experiences with family, friends, culture, education.

• Nurse’s today challenges is he need to provide care for patients from diverse backgrounds.

• Value clarification process allows individuals to

discover their values by assessing, exploring, and detmeining what those vales are and they influence their own thoughts.

• Nurses should be open, a ware, and in control of their feelings so that they can be used to help patients.

• The feeling that nurses have serve an important purpose as barothers for feedback about themselves and their relationship with others.

• The nurses feelings are valuable clues to the patients.

• Formal helpers have a strong influence on those they help.

• The nurse may object, saying that it is possible to separate one’s personal life from one’s professional life.

• The nurse’s approach to life must convey growing, hopefulness, and adapting.

• Is the concern for the welfare of others.

• Every one seeks a certain amount of personal satisfaction and fullfiment from work.

• It can apply to changing social conditions to meet human welfare needs.

• One goal of the all helping facilitating society.

• Personal believes about people and society can serve as conscious guidelines for action.

• code for Nurses reflects common values

regarding nurse –patient

• Sense of ethics is the need to assume

responsibility for behaviors.

• Is the art of Transferring or Exchanging ideas and information or thoughts.

• It is done Verbally or non Verbally.

• Occur through words, spoken or written.

• Verbal communication can convey factual information accurately and efficiently .

• It is less effective .• 7% of meaning is transmitted by

words.

• It represent a small part of total human communication

• Includes all relayed information that does not involve the spoken or written words.

• 38%by paralinguistic cures .

• 55%transmitted by body Cues.

Types of non verbal Behavior

• Verbal acues: speech pitch.

• Action Cues : body movement.

• Object cures.

• cultural art facts.

• Touch:- personal space and action.

Interpretation of non-verbal communication

Sociocultural background

is a major influence on the meaning of nonverbal behavior.

Therapeutic Dialogue

Patient

• (Shifting nervously in his chair, eye scanning the room and avoiding the nurse)What…. What do you want to talk about?

I Sense that you are uncomfortable talking to me . Could u describe , how u are feeling.

You are not sure what we should be talking about, and you want me to start us off?

You look very nervous, and I can feel those same feeling in me as I sit here with you

Communication process

• Defined as a sending-receiving process.

Component of the structural model of communication.

• Sender:-the originator of the message.

• The message is the information that is transmitted from the sender to the receiver .

• The Receiver is the perceiver of the message .

• The feedback is the verbal and behavioral response of the receiver to the sender.

• The context is the setting in which the communication takes places.

Example of therapeutic Dialogue in structural model

.total agreement between the verbal and nonverbal communication.

-Verbal level :- I am pleased to see you.

-nonverbal level:- warm tone of voice , continue eye contact , smile.

Transactional Analysis model

• Is the study of the communication or transactions that takes place between people.

• It uncovers the unconscious and destructive way in which people relate to each other.

• It provides the nurse the framework for the nurse to use in exploring the patient recurrent behavior.

Transactional Analysis model

Complementary Transaction Dialogue

-I know that when I get mad at my boss, I take it out on my wife and kids.

• Nurse:-

-Are you ready to think about some other way you can handle your anger?

• Patient:-

Crossed Transaction Dialogue

-I know that when I get mad at my boss, I take it out on my wife and kids.

• Nurse:-

-Men always think that ‘is ok, but the women have to suffer for it.

• patient

Ulterior Transaction• Patient:- I know that when I get mad at my boss, I

take it out on my wife and kids, but know what else to do.

• Nurse:- do you think you could let your boss know how you are feeling?

• patient:-He will fire me sure.• Nurse: perhaps you could talk it over with a co-

worker .• Patient:- I don’t’ have time to chat on the job like

that.• Nurse:-sometimes physical exercise helps people

get rid of their anger. Have you ever tried it?

Therapeutic Communication Techniques

• Two requirement for therapeutic communication:

-All communication must preserve the self-respect of both individual.

-One should communicate understanding before giving any suggestions or advise.

Therapeutic communication Technique

• Listening:

• the first rule of a therapeutic relationship is to listen to the patient.

• It is an active , not passive , process.

• The nurse should stop thinking of own personal experience

Therapeutic Communication Technique

• Broad openings:-• It lets the patient to

select topics to discuss.

- E.g., what are thinking

about?- Can you tell me more

about that ?

Therapeutic Communication Technique

• Restating :--the nurse repeats of the

main thought the patient expressed.

-it indicates that the nurse is listening.

-it brings attention to something important that might was passed over.

Therapeutic Communication Technique

• Clarification :-

-occurs when the nurse attempts to put into words vague ideas or thoughts

Therapeutic communication technique

• Focusing:-- Helps the patient

expand on a topic of importance.

- Help the patient to be specific.

- effectively used.

Therpuetic communication Technique

• Sharing perceptions:- -involves asking the to

verify the nurse’s understanding of what the patient is thinking or feeling.

-paraphrasing-implied feelings of

nonverbal.

Therapeutic Communication technique

• Silences:-

-lack of verbal communication for a therapeutic reason .

-e. g; sitting with the patient and nonverbally communicating interest.

Therapeutic communication technique

• Humor:- • The discharge of energy

through the comic enjoyment of the imperfect.

• It is constructive coping behavior .

Therapeutic Communication technique

• Suggestion:-

-Presentation of alternative ideas for the patient consideration relative to problem solving.

3. Responsive Dimension

• The nurse must possess certain skills or qualities to establish and maintain a therapeutic relationship.

• It helps the patient to achieve insights.

• Includes: Genuineness , Respect, empathetic understanding , concreteness.

Genuineness

• Means the nurse is an open, honest, sincere person who is actively involves in the relationship .

• The nurse shows must be real and not merely professional" Response that has been learned and repeated.

Respect• Unconditional positive regard.• It does not depend on the patient

behavior.

• The patient is regarded as a person of worth and is respected.

• Nonjudgmental.• • Without criticism ,ridicule.

Empathetic understading

• Is the ability to enter into the life of another person .

• Empathy is an essential part of the Therapeutic process.

Concreteness • Involves using specific terminology

rather than abstraction.

• It keeps the nurses response close to the patient feeling’s and experience.

• It fosters accuracy understanding by the nurse.

• It encourage the patient to attend to the specific problem

4. Action Dimension

• The action-oriented conditions for interpersonal relationships .

• upwards and outwards by identifying obstacles to the patient progress and behavior change.

1. Confrontation2. Immediacy3. Nurse self-disclosure4. Emotional Catharsis5. Role playing

confrontation

• Is the expression; by the nurse of perceived discrepancies in the patient behavior.

• Confrontation requires high levels of empathy.

• Important in pointing out when the patient has developed insight but has not changed behavior.

Immediacy

• Involves focusing on the current interaction of the nurse and the patient in the relationship.

• Involves sensitivity of the patient feelings.

Nurse- self Disclosure

• Personal statement about the self , intentionally revealed to another person.

• It is an index of the closeness's of the relationship and involves a particular kind of respect for the patient.

Emotional Catharsis

• Occur when the patient is encouraged to talk about things that are most bothersome.

• It brings fears, feelings• The expression of feeling can

be very therapeutic in itself.

• Involves acting out a particular situation.

• It increases the patient’s insights into human relations.

• Can deepen the ability to see the situation from another person’s point of view.

• Are blocks in the progress of the nurse-patient relationship.

• Impasses provokes intense feeling in both the nurse and the patient.

– 4 specific therapeutic impasses :-

-Resistance, Transference, Counter transference,

Boundary violation.

• Is the patient’s reluctance or avoidance of verbalizing or experiencing troubling aspects of oneself.

• It comes in form of suppression or repression of the pertinent information.

• It might be a superficial talk .

• Is an unconscious response in which patient experience feelings and attitudes towards the nurse that were triggered by facial features, or manner of speech.

• Is a therapeutic impasse created by the nurse’s specific emotional response to the qualities of the patient.

• E.g., Reactions of intense love or caring. or Reaction of intense anxiety.

• It occurs when a nurse goes outside the boundaries of the therapeutic relationships.

• E.g:-1. the patient takes the nurse out to lunch our

dinner.2.the patient gives the nurse an expensive gifts.